Duly Completed Form Alongwith Necessary Attachments Are to Be Submitted in Single Copy

[Operate]

RED PLUS/ORDINARY RED/ ORANGE

Duly completed form along with necessary attachments are to be submitted in single copy

TripuraState Pollution Control Board

Parivesh Bhawan,Pandit Nehru Complex, Agartala, Pin: 799006, Tripura

Ph-2322462/2222455/2328792,Fax-(0381)-2225421

Application for Consent to Operate
for
Red Plus, Ordinary Red & Orange Category Industry/Operation/Process/Activity

Application under Section 25 and Section 26 of Water(Prevention and Control of Pollution) Act, 1974 andunder Section 21of the Air (Prevention and Control of Pollution) Act, 1981 for Consent to OperateIndustry/Operation/Process/Activityrequiring discharge of effluent and causing emission

Date of submission□□□□□□□□

ToFrom( Name and address of the unit)

Member Secretary

TripuraState Pollution Control Board……………………………………………..

Agartala

…………………………………………….

……………………………………………

Sir,

With a view to operating an Industry/Operation/Process/Activity,I/We hereby apply under

(i)Section 25/26 of Water (Prevention & Control of Pollution) Act, 1974 for disposal of sewage/trade effluent/any other effluentson land/water body/`river (after pretreatment for conforming to prescribed standards ), and

(ii)Section 21 of Air(Prevention & Control of Pollution) Act, 1981 for release of emissions into atmosphere (after pretreatment for conforming to prescribed standards ) originating from

M/s………………………………………………..ownedby………………………………

for its unit located at……………………… ……………………………………………….

……………………………………………………………………………………………..

2. The Annexure, Appendices, other particulars and plans are attached .

3. I/We further declare that the information furnished in the application form, Annexure/Appendices and plans is correct to the best of my /our knowledge.

4. I/We hereby submit that in case of a change either of a point or the quantity of discharge or the quantity of emission, a fresh application for consent shall be made and until such consent is granted, no change shall be made.

5. I/We hereby agree to submit to the Board, application for renewal of consent one month in advance of the date of expiry of the consented period, if to be continued thereafter.

6. I/We undertake to furnish any other information within seven days of its being called for by the StateBoard.

7. I/We enclose herewith Draft/Banker’s Cheque No………………………… of Rs………….. ………………….… (Rupees ……………….….……..……………….…)

deposited at………………………………Branch dated ……………………………….in favour of Member secretary,Tripura State Pollution Control Board being the ‘Consent to Operate application fee’.

Date (Signature.……...... )

Seal………………………………

Name of the applicant …………………………………………………………………

Designation ...... ……...... ………...... …

(Proprietor/Partner/Managing Director/ Authorised Representative):

Application on behalf of…………………………………………………………………….. ……..

Address of applicant……………………………………………………………. …….

PART - A : (GENERAL INFORMATION)

01. Full address of the proposed factory (mentioning Post Office, Police Station, Urban Local body/Panchayet with Ward No. etc.):

...... ………………...... …………………

Telephone ………………………………… Fax ……………………………………..……

Mobile.No………………………e-mail….……………………………………………….

website……………………………Police Station…………………..…………………….

P.O….………………….. Pin Code ………………………………………………………

Urban Local Body/Panchayet………..………………………………………………

Ward No………………………..Subdivision……………………………………

District………………..Mouza.No & Sheet No………………………………….

Plot No./Dag No. …………..………………………………………

02. Permanent Residential Address /Correspondence/ of the owner

(Proprietor/Partner/Managing Director/ Authorised Representative):

...... ………………...... …………………

Telephone ………………………………………………Mobile……………………..

Fax …………………..e-mail …………………………………………………………….

website…………………………………………………………………………………….

03. a) Size of industry (Large /Medium/ Small/) : …………………..…..…………………….

b) Power Supply Agency at the factory premises

[viz. Tripura State Electricity Corporation Ltd/Others (Specify)]

…………………..…………………………………………………………………………

04. Year of commissioning of the industry : ..……………………..………………………

05. (i) Number of persons engaged by the factory

a) Workers (including contract engagements) : ..……………………..……

b) Management Staff : ..……………………..…………………..

c) Others (Night watchman etc.) : ..……………………..……….

(ii) a) No. of working hour per day: : ..……………………..……

b) No. of working day per year: : ..……………………..……….

06. Population residing in the Quarters / Colony, if applicable :

..……………………..…………………………………………

07. Gross capital investment on land, building, plant & machinery excluding capital investment on pollution control system of the unit till the date of application

Rs. …………………..…….

(To be supported by an undertaking/affidavit/annual report or certificate from a Chartered Accountant)

08. Give the list of raw materials (including fuel) with consumption per month (If the space provided below is found inadequate, please attach separate sheet giving information using the same format )

Sl. No. Name of Raw Materials(including fuel) Quantity per Month

...... …………...... …..

...... …………...... ….

09. List of products and by-products manufactured :

(If the space provided below is found inadequate, please attach separate sheet giving information using the same format )

Name Production Capacity Average Production

(Per Month) (Per Month)

......

PART-B : INFORMATION REQUIRED IN CONNECTION WITH PREVENTION AND CONTROL OF WATER POLLUTION

10. Water consumption for different uses

Type of Use Sources of supply Quantity (Strike out which is/are not applicable) (M3/day)

a) Industrial cooling, Municipal supply/ Well / Tube well

spraying in mine pits /Canal / River/Others (please specify)

boiler pits

b) Domestic purpose Municipal supply / Well / Tube well /

(drinking, bathing, canteen Canal / River / Others (please specify)

use, etc.)

c) Processing whereby water getsMunicipal supply / Well / Tube well /

polluted and the pollutants areCanal / River / Others (please specify)

easily biodegradable

d) Processing whereby water getsMunicipal supply / Well / Tube well

polluted and the pollutants areCanal / River / Others (please specify)

not easily biodegradable

e) Others Municipal supply / Well / Tube well /

Canal / River / Others (please specify)

11. Information regarding liquid waste discharged

(Do not give information on storm water discharge)

OutletNature Sources Quantity Place of discharge

No.(Industrial / Domestic / Mixed) (Place of generation) (M3/day)

...... ………......

...... ……… ......

...... ………......

(If the space provided above is found inadequate, please attach separate sheet giving information the same format)

(Note : Please attach a diagram showing liquid waste flow from its place of generation upto the of final discharge.)

12. Indicate available information on process waste water characteristics

(beforetreatment) :

PHYSICAL / CHEMICAL
Parameter / Expected
value / Parameter / Expected
value / Parameter / Expected
value / Parameter / Expected
value / Parameter / Expected
value
Temperature
(°C)
pH
Colour
Turbidity (JTU)
Odour
Total Solids (mg/l)
Total Suspended Solids (mg/l) / Total
volatile
solids
(mg/l)
Oil &
Grease
mg/l / BOD
COD
mg/l
Heavy Metals
mg/l
Toxic
Elements
(mg/l) / Spent
Chemicals

[Please mention any other relevant parameter in space above]

[Attach additional sheet if necessary using the same format]

13. Whether facilities available for liquid waste treatment : Yes / No

if yes,

(a)Quantity of Liquid waste treated : ...... ……………

(b) Describe the facility along with a diagram : ...... ….

(Please attach separate sheet)

14. Attach latest ‘analysis report’ of the Board or Board’s recognised laboratory showing quality of liquid waste discharge (before and after treatment):

15. Whether water meter at water intake points installed : Yes / No

16. Whether energy meter of E.T.P. installed : Yes / No

17. Whether wastewater flow measuring device installed : Yes / No

PART-C :INFORMATION REQUIRED IN CONNECTION WITH PREVENTION AND CONTROL OF AIR POLLUTION

18. Details of source of emission

Sources of Emission / No. of Units / Capacity of
each unit / Fuel (Nature
Quantity) / Air Pollution
Control Systems
provided / Height of stack
from Ground
Level
(A) From Process
(B)Blast /Cupola/Rotary/
Revervatory/Induction/
Arc/other Furnace
(C) Heater
(D) Kiln
(E) Boiler
(F) Others

[Attach additional sheet if necessary using the same format]

19. Diesel Generator Sets

i) No. of DG Sets :

ii) Capacity of each DG sets :

iii) Height of the stack above DG room :

iv) Height of the DG room :

v) Noise pollution control measures

a)Acoustic enclosure/acoustic treatmentof DG room :

b) Exhaust muffler

20. Emission details

Stack
No. / Stack attached to / Fuel
(Nature& Quantity) / Inner diameter / Height from
ground / Flow
rate Nm3/hr / Particulate
Matter mg/Nm3 / SO2 mg/Nm3 / Others pollutants,
if any / Description of air Pollution
control devices, if any
Top / Bottom

(If the space provided above is found inadequate, please attach separate sheet giving information using the same format)

(Attach latest ‘analysis report’ of the Board and Board’s recognised laboratory)

PART - D : OTHER INFORMATION

21. Give details regarding solid waste

Type of waste / Description of waste (Lump/Paste/Dust, etc.) / Composition / Qty./day / Treatment and disposal method
a) Waste from Process
(b)Waste from Effluent
Treatment Plant
(c)Waste from Air pollution
control units
(d) Rejected materials
(e) Others, if any

22. Attach a separate sheet (not applicable to small scale unit) :

providing a brief write-up and schematic flow sheet of the manufacturing process clearly showing sources of generation of solid (hazardous and, non-hazardous)liquid and gaseous wastes

23. Attach layout plan clearly showing the different outlets for liquid waste discharge:

Names Daily Qty.

24.(a) Hazardous Chemicals to be handled

[Refer-Manufacture, Storage and

import of Hazardous Chemicals

Rules, 1989 (MSIHC)]

(Attach separate sheet if necessary)

(b) Maximum quantity of Hazardous

Chemicals to be stored at a time

[Refer-Manufacture, Storage and import of

Hazardous Chemicals Rules, 1989 (MSIHC)]

(Attach separate sheet if necessary)

25. Pollution Control Management

(a) Specify Environmental Management Plan including Monitoring

(b) Give brief organisational set up as per declaration given above

26. Other relevant information, if any :

(Please attach separate sheet if required)

Seal Signature of Applicant......

Check-list of accompaniments:[Please put tick mark (√ ) as applicable]

1.Detailed Project Report including details of Raw Materials and Fuel use, details of

ProcessDescription, Specification and details of Plants and Machinaries, CostAnalysis

Data.

2. Undertaking/Affidavit/Annual Report/Certificate from a Chartered Accountant

3. Site Plan

4. Land and Building Valuation Certificate/Documents

5.Agreement Copy of rent between the unit & the land owner if the land/building is

rented.

16. NO objection Certificates from surrounding neighbours of the unit.

17. Land Diversion Certificate from Concerned authority (if required)

18. Draft /Banker’s Cheque

19. Photocopy of Last Year’s Consent Certificate .

10. Undertaking/Affidavit/Annual Report/Certificate from a Chartered Accountant

against Item No.07

11. Additional sheet against Item No.08

12. Additional sheet against Item No.09

13. Additional sheet against Item No.11

14. Additional sheet against Item No.12

15. Additional sheet against Item No.13(b)

16. Additional sheet against Item No.14

17. Additional sheet against Item No.18

18. Additional sheet against Item No.20

19. Additional sheet against Item No.22

20. Additional sheet against Item No.23

21. Additional sheet against Item No.24(a) &24(b)

22. Additional sheet against Item No.25(a), 25(b)& 25(c)

23. Additional sheet against Item No.26

Notes :

All enclosures, documents and analysis reports of Board’s recognised laboratories must be signed/counter-signed by the applicant with official seal.
All subsequent correction in the application form and enclosures should be signed by the applicant or any person authorised by the applicant.
The form is to be filled preferably in by typewriting or legible hand writing.
Applicant is to give full signature in each page of the form.
Banker’s Cheque/Demand Draft should be made from any Nationalised Bank.

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